2010-201 - Bulloch County

Transcription

2011 ALCHOHOL LICENSE RENEWALS
RECO~NDATION:APPROVAL
FARM WINERY
Meinhardt Vineyards - Mr. Kenneth Meinhardt
ON-PREMISES
Forest Heights Country Club - Mr. Stacy Webb
Statesboro Moose Lodge - Mr. James Stalnaker
OFF-PREMISES
Stilson Country Store - Mr. Gerald Forehand
H's Food Mart - Mr. Michael Hatten
The Country Store - Mr. James Revell
Quick Stop - Vikash Chitroda
Mill Creek - Mr. Paul Uelmen
El Cheapo #89 - Mr. Suresh Patel
Clyde's Market #40 - Mr. Gregory Woolard
Fast & Easy III - Mr. Brook Hallat
Clyde' s Market #74 - Mr. Gregory Woolard
Eldora Penny Saver - Mr. Edward Maddox, Sr.
Neighbors #95 - Mr. Matthew McGhee
Zip-N-Food #8 - Mr. Suren Patel
EI Cheapo Food Mart - Mr. Jayeshkumar Patel
Zip-N-Food #1 - Mr. Suren Patel
301 BP - Mr. Fagnukumar Patel
PoJo's #2 - Mr. Phillip Sumer, Mr. Jimmy Sumner Jr., Mrs. Connie Sumner, and Mrs. Beverly
Sumner
Minit Mart #3 - Mr. Narinder Kaur
Jay Food Mart - Mr. Pratik Pandya
Country Club Food Mart - Ms. Pallavi Patel
Mill Creek Motor Mart - Mr. Paul Uelmen
Ace Stop & Go - Mr. Dipakkumar Patel
Zip N Food #11 - Mr. Mitul Patel
Zip N Food #12 - Mrs. Meenaben Patel
Zip N Food #17 - Mr. Suren Patel
Zip N Food #16 - Mr. Suren Patel.
301 Food & Gas - Mr. Samir Patel
.Q
0\0 -aO~
Exhibit No . ~
C~P::::"" __",,,
_
,,-=~
2011 ALCHOHOL LICENSE RENEWALS
RECOMMENDATION :
DENIAL OF RENEWAL
Sec. 3-29. Qualifications.
(a) A licensee or designee must be at least 21 years of age, of good moral character and a
citizen of the United States. A licensee must be a resident of Bulloch County, except that the
named licensee shall not be required to be a resident of Bulloch County if the named licensee
designates a resident of Bulloch County who shall be responsible for any matter relating to the
license (i.e., a "designee").
OFF-REMISES
Sun Fly #2 and Sunfly #3 - Ankurkumar Pat! (Mr. Patel was arrested in Toombs Count on
5/13/10 for Commercial Gambling (F), Violation of the Georgia RICO Act (F), and for Keeping
a Gambling Place (F). Although Mr. Patel has not convicted, these are serious charges
(especially the violation of the RICO Act. In addition, Mr. Patel lied on both applications stating that he had never been arrested. Mr. Patel signed the SWORN STATEMENT OF
APPLICANT, which states that all the information on the application is true and correct.)
A to Z Truck Stop - Luther Rogers ill (Mr. Rogers also lied on his application about being
arrested. His arrests were in 1992 and 1996)
SHERIFF
17257 HWY 301 NORTH
STATESBORO, GA 30458
(912) 764-8888
FAX (912) 764-2917
LYNN M. ANDERSON
The following information is furnished to the Bulloch County Board of Commissioners,
in regards to an application for a beer and Wine License. This information is
furnished by the Bulloch County Sheriff's Department for the purpose of the Board
in their decision on the issuance of a license.
NAME:
Ih f
4t
t:««ltV (JriIe!
G I.:( Af(y -jJ... 2--LOCATION: 00 I <SA- (tW'{ d- c.f
BUSINESS:
56b&1W
CRIMINAL HISTORY :$ e
e...
fr!k k.ci
REsrnENcr:£~_~
________________________________________________________
This information is furnished to the Bulloch County Board of Commissioners for their
informati
only at their request".
This
If
Day of
f2ct:
~~
"The sheriff shall keep and preserve the peace of his county."
,20/t2
·')(5~/
",.-i n
/
BULLOCH COUNTY, GEORGIA
APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE
*1'OU MUST COMPLETE APPLICATION IN ITS ENTIRETJ'*/
DATE OF APPLICATION
NEW
RENEWAL--"'--_ _
Type of Business to be operated:
_ _ Retail beer and wine packaged only
_ _ Retail beer and wine by the drink (pouring license)
_ _ Retail liquor by the drink (pouring license)
_ _ Pouring license (beer, wine, and liquor)
Wholesale license
_ _ Farm Winery
_ _ Catering License (off premise)
_ _ Application Fee (due UpOIl retllmillg applicatioll)
Event Permit
License Transfers
_ _ Temporary Permit (all forms)
Total license fee (include the application fee)
*Late Penalty
$1,500.00
$1,500.00
$3,000.00
$4,500.00
$1,200.00
$2,250.00
$ 500.00
$ 250.00
$ 50.00
$ 250.00
$ 250.00
$
---
*
All renewal applications received after November 1 and before January 1 - 25% of license
fee
AU renewal applications received after January 1 - 50% of license fee
Applicant's full name (tNI<l2 B 1<' U !f)81\ . IAHflliS HA yltfllBHr1f Pfn '7- L
Name of business
CO lJ..n PI'd- :I\. 'L
Location of business
5qQ\
CAf\ 1-\\01/ ,9.,-/
S+C!"rs.\W~(j~IAI!\ ~~1l\l101
Type of business organization (Corporation, limited liability company, partnership, etc.)
b· b • . C,
Business mailing address
Applicant's home address f).Cf :# A PerT? L
Applicant's age :2 en
Date of birth
Pi.... .
Phone 9 I 'l \0 '67 J./ 5 ~ ~
Phone _ _ _ _--,_----::Security #
Are you ay:sident u.s. Citizen?
YES-1L
NO
".
Are you a resident of Bulloch County?
YESVNO_
If "No", thell you mllst designate a residellt of Bulloch Coullty who shall be respOll sible for
any matter relating to the licellse (ie., a "designee"). If you are appoilltillg a desigllee, provide
the following informatioll:
Designee's Name & Home Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Designee's Age _ _ _ _ _ _ __
Designee's Home Phone _ _ _ _ _ _ _ __
Designee's Date of Birth _ _ _ _ _ _ _ __ Designee's SS# _ _ _ _ _ __
Are you the owner of the business?
YES ,/
NO _ _
If "Yes", attach documentation demonstrating your olVllership of the business, such as an
Operating Agreement, Partnership Agreement, or Share/wIder's Agreement.
If"No", what is YOllr title or interest ill the busilless? _ _ _ _ _ _ _ _ _ _ _ _ _ __
List all partners, shareholders, members, or managers of the business below :
Attach a copy ofyour business's Certificate of Existence from the Secretary of State's office.
BE ADVISED THAT ANY PARTNER, SHAREHOLDER, MEMBER OR MANAGER LISTED
ABOVE MUST COMPLETE A SEPARATE APPLICATION AND CONSENT FORM FOR A
BACKGROUND CHECK AND IT IS YOUR RESPONSmILITY TO ENSURE TmS IS DONE.
Has the applicant or designee EVER been arrested for anything other than a traffic violation?
"'A
YES
NO
If "Yes", attach a detailed explanation to this application, and be sure to prOl'ide the date,
jurisdiction, offense, and circumstances of the arrest.
as the applicant or designee ,E VER been denied an alcoholic beverage license?
YES
NO
'f,
If "I'es", attach a detailed explanation to this application, and be sure to prOl'ide the date,
County or City, and circumstances of the denial.
\
Has the applicant or designee EVER had an alcoholic beverage license suspended or revoked?
YES
NO
lj"Yes", attach a detailed explallatioll to this applicotioll, and be sure to provide tlte date,
County or City, a/ld circllmstances o/the suspensioll or revocatioll.
'1
Approved _ __
Rejected _ __
This _ _ day of _ _ _ _ _ , 20_.
Bulloch County Board of Commissioners
By:
--~~~~~~-----
J. Garrett Nevil, Chairman
Attest: _---:-:---:--::--=_ _:-:---=:---:Maggie R. Fitzgerald, Clerk
CONSENT FORM
I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, hereby authorize the Bulloch County
Sheriff's Department to release infonnation on any criminal history record the State of Georgia
or the Bulloch County Sheriff's Department might have access to concerning me to the Bulloch
County Board of Commissioners and its agents or employees.
I hereby agree that the Bulloch County Sheriff's Department, the Georgia Crime Infonnation
Center, the employees of either agency, or any other agency or employees of the county, state or
federal government, shall not be responsible or liable for defamation, invasion of privacy,
negligence or any other claim in connection with any dissemination of infornlation pursuant to
this record check.
FULL NAME: .ftNIZ()A gorY) &8, {(HA NSHfl\1
Print or Type
,5CjC)\
ADDRESS:
Arn0HA:r....
\,<1& t-\uJ~ ~l...\
6c1.\(p \
Street Address
SEX: M'f)\~
Zip Code
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
f
Signature
Sworn to and subscribed before me this
3D ff1 day of Stl)/;empv
, 20JL.
~/ X~ )
Notary Public
. Mv CommIssIon ExpIres Nov. 4. 201 \ .
ea n· 1--
Date
SWORN STATEMENT OF APPLICANT OR DESIGNEE
ka£1£W7;$v e
,
I,
hereby provide this statement under oath in
support of the application of AI-1p,v gKIJ{ort~ (j)''l-T'rL(name of applicant) for an alcohol
license pursuant to the provisions of the Bulloch County Alcohol Ordinance.
1.
I am at least twenty-one (21) years of age, of good moral character, and a citizen of the
United Sates.
2.
I am a resident of Bulloch County, Georgia, or, if an applicant who is not a resident of
Bulloch County, Georgia, I have designated a resident of Bulloch County, Georgia who
shall be responsible for any matter relating to the license.
3.
I have not been convicted ofa felony or of any violations of the laws of the state of
Georgia, or any other state, relating to the sale of alcoholic beverages within five (5)
years ofthe date of this application.
4.
I have not been denied or had revoked, within the five (5) years next preceding the date
of this application, any license to sell alcoholic beverages issued by any governmental
entity.
5.
I have read' the Bulloch County Alcohol Ordinance in its entirety and am familiar with
and understand the same, including but not limited to the qualifications, regulations, sales
to persons under the age of twenty-one (21), and 50% food requirement for licensees who
serve alcohol for on-premises consumption. I understand that the holding of an alcohol
license is a mere privilege subject to all the terms and conditions of said Ordinance.
6.
By execution of this affidavit and in consideration of the issuance of any license issued as
a result of this application, I agree to be bound by every provision of said Ordinance and
understand and agree that a violation of any provision of said Ordinance or of any law or
regulation of the state of Georgia pertaining to the sale of alcoholic beverages may
subject me to suspension or revocation of this license or criminal charges, or both.
I swear and affirm that every entry. upun fIlY ,application .is true and correct. I understan
and acknowledge that false or misleading information contained in my application is
grounds for denial of my application or revocation of my license.
Signature of Applicant or D sIgnee
Sw~~o
,
and subscribed before me this'
day of Sq:J+, 20In.-.
Affidavit Verifying Status for County Public Benefit Application
By executing this affidavit under oath, as an applicant for a Bulloch County, Georgia Business
Occupation Tax Certificate, Alcohol License, Taxi Pennit or other public benefit as referenced in
O.C.G.A. Section 50-36-1 , I am stating the following with respect to my application for a
BulJoch County Business Occupation Tax Certificate, Alcohol License, Taxi Pennit or other
Itl C 7) \r),\')\
\ \ C s.:x--s,9public benefit (circle one) for
[Name of natural person applying on behalf of individual, business, corpol1rtfon, partnership, or
other private entity1 .
I)
'\•/1 am a United States citizen
OR
2)
I am a legal permanent resident 18 years of age or older or I am an otherwise
qualified alien or non-immigrant wlder the Federal Immigration and Nationality Act 18 years of
age or older and lawfully present in the United States. *
In making the above representation under oath, I understand that any person who
knowingly and willfully makes a false , fictitious, or fraudulent statement or
representation in an affidavit shall be guilty of a violation of Code Section 16-10-20 of
the Official Code of Georgia.
Signature of Applicant:
Date
A---\?'~
Printed Name:
SUBSCRIBED AND SWORN
BEfORE ME ON THIS THE
DA Y OF ,
, 20J£?
!!lJ!!2
*
9.ptfflZW
----~--~--~~--------
Alien Registration number for non-citizens
Public~/lz/ f). ~
Notary
My Commission Expires:
Q/lyOommlulon Explrus NOI'. 4, 201 ~
*Note: O.C.G.A. § 50-36-I(e)(2) requires that aliens under the federal Immigration and
Nationality Act, Title 8 U.S.c., as amended, provide their alien registration number. Because
legal penn anent residents are included in the federal definition of "alien", legal pennanent
residents must also provide their alien registration number. Qualified aliens that do not have an
alien registration number may supply another identifying number below:
".
:. '~~ '"
\.
. . ... .
,~
*YOU MUST COMPLETE APPLICATION IN ITS ENTIRETY*
DATE OF APPLICA nON
Type
/
RENEW AL_~~
__
NEW
ofBusin~
to be operated:
_V_ RRtetail beer and wine packaged only
_ _ Retail beer and wine by the drink (pouring license)
_ _ Retail liquor by the drink (pouring license)
_ _ Pouring license (beer, wine, and liquor)
$1,500.00
$1,500.00
$3,000.00
$4,500.00
$1,200.00
$2,250.00
$ 500.00
Wholesale license
_ _ Farm Winery
_ _ Catering License (off premise)
_ _ Application Fee (due UpOIl retumillg applicatioll) $ 250.00
$ 50.00
Event Permit
License Transfers
_ _ Temporary Pennit (all forms)
$ 250.00
$ 250.00
$ \
f)Q).aD
i
*Late Penalty *
fee
All renewal applications received after January 1 - 50% of license fee
Applicant' s full name flNIS[)R}q2n'\ft~ CBHfrNsHfl'jfrfCl'BHft,j;.. ff\-T'i
Name of business _ _~5..L::\..l...!'YlL.L..JFL.LIOH-....:;ft:u......3-,-_ __ _ _ _ _ _ _ _ _ _ _ _ _ __
L-
'09'0
/...0/<£ Uh;IJ 'fusd i 'S±<:.tTIs'knt,Q;J -{Aft
Type of business organization (Corporation, limited liabili company, partnership, etc.)
Business mailing address '5910, j.,q k~ vi'" v.J PPCi(~.
Phone
Applicant's home ad~ress p?9411l P frY? /?L.
Phone
Applicant's age
C,
Date of birth
Social Security #
g
Are you ardent U.S. Citizen? .
YES -.IL.
NO
.
'.
3D'-\57'
9 12 ?i KJ LIS SS
732. '0'2.2. S'l <.j 7
Are you a resident of Bulloch County?
YES
NO
V
/f"No ", thell YOllmust designate a residellt 0/ Bulloch COUllty who shall be responsible/or
any matter relating to tlte license (ie., a "designee',). I/yoll are appointing a designee, provide
the following in/ormation:
Designee's Name & Home Address _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ __
Designee' s Home Phone _ _ _ _ _ _ _ __
Designee' s Age _ __ _ _ _ __
Designee's SS# _ _ _ _ _ __
Designee's Date of Birth _ _ _ _ _ _ _ __
Are you the owner of the business?
YES - . /
NO - - -
/f"I'es", attach docillllentation demonstrating your ownership o/the business, sllch as OIl
Operating Agreement, Partnership Agreement, or Shareholder's Agreement.
/f "No", wllat is YOllr title or interest in the business? _______________
List all partners, shareholders, members, or managers of the business below:
Attacll a copy 0/YOllr bllsiness's Certificate 0/ Existence/rom the Secretary 0/ State's office.
BE ADVISED THAT ANY PARTNER, SHAREHOLDER, MEMBER OR MANAGER LI STED
ABOVE MlJST COMPLETE A SEPARATE APPLICATION AND CONSENT FORM FOR A
------
BACKGROUND CHECK AND IT IS YOUR RESPONSffilLITY TO ENSURE THIS IS Q
Has the applicant or designee EVER been arrested for anything other than a traffic violation?
Y..
YESL
NO
I/"I'es", attach a detailed explanation to tllis application, and be sure to prOl'ide the date,
'IIrisdiction, offense, and circllmstances o/tlle arrest.
Has the applicant or designee EVER been denied an alcoholic beverage license?
YES
NOrI/"I'es", attach a detailed explanatioll to tllis application, and be SIIre to provide tile date,
COllnty or City, and circumstanct;s o/the denial.
\
NO
"t
YES
If "Yes", attacll a detailed explanation to this applicatioll, alld be sure to provide the date,
COllllty or City, and circumstallces of tile sllspellsioll or revocatioll.
Approved _ __
Rejected _ __
This _ _ day of _ _ _ _ _ , 20_
By:_~~_~~~~_ __
J. Garrett Nevil, Chainnan
Attest: _ _ _ _ _ _ _ _ _ _ __
Maggie R. Fitzgerald, Clerk
\,
,
CONSENT FORM
I,
, hereby authorize theulJoch COUnty
Sheriff s Department to release information on any criminal history rec°the State of G
.
eorgla
or the Bulloch County Sheriffs Department might have access to concer~ me to th B
?
e ulJoch
I hereby agree that the Bulloch County Sheriff s Department, the
Georgi~e
Inti
.
OmlatJon
Center, the employees of either agency, or any other agency or employeeie co
unty, state or
federal government, shall not be responsible or liable for defamation, invifpr'
IVacy,
negligence or any other claim in connection with any dissemination of intm p
ursUant to
this record check.
FULL NAME:
AWZI2(2.g,tJlVltJ(t,
WliAMSHfI Yftn'\13{1Jtl., ref-..-
---=..--_
Print or Type
ADDRESS:
590 I fR/3- HWy JLI 8tctf L'tborgQ
Street Address
SEX: D'l A/", 'L
City
,
RACE: frSIC/O
•
~ ~(Jr. '..!::J
c, I
State ~ip COde
DATEO
A- -IA ~
Signature
[0// 4
Date
SW9rn io and subscribed before me this
, 20~.
_1_'1_ day of OChh.e...---
~tfv£i
Notaryblic
RUBy HUNTER
Notary Public
Bulloch County
M
State of Gi!orgia
.YCOmmission 1;'- ' 0
"",!,Ires etaber 19, 2012
'.
~
, J~ ~~
,
i,
hereby provide tlns statement under oath in
support of the application of At'! ~ tJt<-/:(UIY}8P-- Pfr'{'f h-(name of applicant) for an alcohol
license pursuant to the provisions of the Bulloch County Alcohol Ordinance,
1.
i am at least twenty-one (21) years of age, of good moral character, and a citizen of the
United Sates.
2.
3.
I have not been convicted ofa felony or of any violations of the laws of the state of
years of the date of this application.
4.
I have not been denied or had revoked, witllin the five (5) years next preceding the date
oftlns application, any license to sell alcoholic beverages issued by any governmental
entity.
5.
I have read the Bulloch County Alcohol Ordinance in its entirety and am familiar with
serve alcohol for on-premises consumption. I understand that the holding of an alcohol
6.
By execution of this affidavit and in consideration of the issuance of any license issued as
a result of this application, I agree to be bound by every provision of said Ordinanclland
understand and agree tllat a violation of any provision of said Ordinance or of any law or
regulation of the state of Georgia pertaining to the sale of alcoholic beverages may
subject me to suspension or revocation of this license or criminal charges, or both.
7.
I swear and affirm that every entry upon my application is true and correct. I understand
Signature of Applicant or Designee
efore me this .
-L~~_ _ ' 20 /6 .
Occupation Tax Certificate, Alcohol License, Taxi Permit or other public benefit as referenced in
O.C.G.A. Section 50-36-1 , I am stating the following with respect to my application for a
Bulloch County Business Occupation Tax Certificate, Alcohol License, Taxi Permit or other
public benefit (circle one) for
~F
.
[Name of natural person applying on lie alf of mdlVldual, busmess, corporatIOn, partnershIp, or
other private entity1
I)
\ / , am a United States citizen
OR
2)
qualified alien or non-immigrant under the Federal Immigration and Nationality Act 18 years of
age or older and lawfully present in the United States. *
knowingly and willfully makes a false, fictitious, or fraudulent statement or
representation in an affidavit shall be guilty ofa violation of Code Section 16-10-20 of
Signature of Applicant:
Date
Printed Name:
SUBSCRIBED AND SWORN
BEFORE ME ON ~6NTER
B .DAY OF Of
PublW.!2
BuJlo~h
N
otary
~~--~------~--~----
County
State of Georgia
PU<myaom(lJj ••ion Rxpires October
hi;
*
19. 2012
*Note: O.e.G.A. § 50-36-I(e)(2) requires that aliens under the federal Immigration and
Nationality Act, Title 8 U.S.C., as amended, provide their alien registration number. Because
legal pennanent residents are included in the federal definition of "alien", legal permanent
alien registration number may supply another identifying nUlllber below:
" "
:J
\
Monday, October 18, 2010
Respo ns e Key :
Page 1
.BUSX -
0453172 GA- CCH 20101018 09:20: 23 2 0101018 09: 20 : 23 201502D19F
Georgia Crime I nformation Center
3121 Panthersvil1e Road
Decatur, GA 30037
(404) 244 - 2639
**********************
CRIMINAL HISTORY RECORD
Produced o n
2010 - 10 - 18
**~ ********** * ****** *** **** *
Int roduction
***********************
******************* **** * ****
This rap sheet was produced in response to the following request:
FBI Number
Sta t e I d Number
iI.RN
Purpose Code
Atte nti on
7 92356HD7
GA3 913 300W (Gil. )
ALR SUNFLYI1 2
E
NEVILS /KCl~
The informat ion in this rap shee t is subject to the £01 1 0\..)'ing caveats :
** THIS RESPONSE IS BEING PRODUCED FOR YOUR REQUES T SENT: 2 010 - 10 - 18
(GA ; 2007 - 08 -11 )
Important! Cri rnina~ history record information is o btain ed one of two
ways : 1) by co nd ucting an inqui r y us ing persona l identifiers such as
name a n d da te o f birth (name s e arch), or 2) by su bmitting fing e rprin t
cards to the Georg ia Crime Informa t i on Ce nt er (GCIC) . When co n ducting a
name search for criminal history record i nformation, there is a
possi bili t y that the information ret urned belongs to a d iffere nt person
wit h the same , or similar, identifiers. In t his case , a pos it ive match
of t he person whose crimi nal h istory r eco rd is sought r e q u ire s
submissi o n of fingerprint c ards to GCIC. When conducting a finge rp rint
search for criminal h i story r ecord inf ormation , the info rma ti on
retu rned does , in fact, belong to t he individual. In this case,
c ond ucting a name se arch using th e indiv id ual's pe rson al ident if iers
would be t h e same information. (GA ; 2007 - 08 - 11 )
When the informati on contained in a crimi nal history report causes an
adverse employment or l icens i ng decision the indi vidual, busine ss o r
agency making th e decision must in fo rm the applicant of all info rmati o n
perti nent to the decision. The disc losur e must in c lude information that
a crimina l hist ory record check was conducted, the specific contents of
the record a nd t he e ff ect th e record had upon the decision. Failure t o
provi de a l l such informati on to t he person sub ject to t he adverse
decis i on is a misdemeanor offens e under Geo rgia la w. Additionally , any
unauthorized diss e minat i on o f this record or information herein also
v i o lates Georg ia la w . (GA ; 2007 - 08 -11 )
I n the event that identifiers are not clearl y ass o ciated to a specif ic
cyc le , t h e information is most"like ly non - fingerprint bas~~ ~~~tiO~'d
received from th e Departmen t of Correct io ns at the time o ~~~~~~e~ ,
inc arcerat io n . (GA ; 2007 - 08 -11)
***** ** ***** * ******* **** ** *
IDENTIFICATION
*******
File
~ountv Sherifs ffice
******J***
.- ~-
Oil
10
\8
Page 2
Subject Name(s)
PATEL , ANKURKUMAR G
(2010 - 05-13)
Subject Description
State Id Number
GA3913300W
FBI Number
792356HD7
Social Security Number
(2010 -0 5 - 13)
Sex
Male (2010 - 05 -1 3)
Asian
He ight
5' 10 " (20 10-05-13)
Weight
150 (2010 - 05 -1 3)
Hair Color
Black (2010-05-13)
Eye Color
Brown (2010 - 05 - 13)
Place of Birth
INDIA (2010 -05-13)
Citizenship
II (20 10-05-13)
III Record
SSO
Race
************************* *
(2010 -0 5 - 13)
CRIMINAL HISTORY
~~~~~~~~~~~~~~~~~~~ ~~ OTN 88374892104
Offender Tracking Number (OTN)
Earli est Event Date
Offense Date
Date of Birth
(2010 - 05 -13 )
**************************
(Cycle 1 of 1 ) ~~~~~~~~~~~~~~~
88374892104
2009 - 06 - 01
2009-06 - 01
Arrest
Arrest Date
Case Number
Arresting Agency
Subject's Name
Arrest Type
(Cycle 1 )
20 1 0 - 05 - 13
100500045
GA 1 380000 TOOMBS COUNTY SHERIFFS OFFICE
PATEL , ANKURKU~~R G
Adult
Charge
Charge Tracking Number
Charge Literal
Charge Description
Statute
COM[~ERCIAL
88374892104-1
GAMBLING
FELONY
16-1 2 - 22; GA
~
State
Offense
Code
3932 ________________------------------------------------__
--------~
s~e~v~e~r~l
~
·t~y~-:Fe~l,Ony
Charge
"\
8837 4892104-2
Charge Literal VIOLATION OF THE GEORGI.l\ RICO (RACKETEER INFLUENCED
CORRUPT ORGANIZATIONS) }\.CT
Charge Desc ri p ti on FELONY
Statute 16-14-4; GA
State Offense Code 7129
Severity Felony
Charge
88374892 10 4 - 3
\.
.~ND
Charge Li te ral
Charge Description
Statute
State Offense Code
Severity
Page 3
KEEPI NG A GAMBLING PLACE
FELONY
16- 12 - 23 ; GA
3959
Misdemeanor
~***** *** **** ***** * ******
Agency
INDEX OF AGENCIES
**************************
TOOMBS COUNTY SHERIFFS OFFIC E; GA13BOOOO ;
SHERIfF
Address
357 NORTHWES T BROAD STREET SUITE 1
LYONS, GA 304360000
* * * END OF RECORD * * * Ua
\
SHERIFF
17257 HWY 301 NORTH
(912) 764-8888
FAX (912) 764-2917
LYNN M. ANDERSON
The following information is furnished to the Bulloch County Board of Commissioners.
in regards to an application for a beer and Wine License. This information is
furoished by the Bulloch County Sheriff's Department for the purpose of the Board
in their decision on the issuance of a license.
This information is furoished to the Bulloch County Board of Commissioners for their
information ouly at their request.
OCR COUNTY. GA.
_---#-"'--~Day
"The sheriff shall keep and preserve the peace of his county."
of
£)m-.20lQ
*YOU MUST COMPLETE APPLICATION IN ITS ENTIRETY*
DATE OF APPLICATION_ _ __
v/
__
NEW_ _ __
RENEWAL'_ _
Type of Business to be operated:
_ _ Retail beer and wine packaged only
__
__
__
__
__
__
__
$1,500.00
Retail beer and wine by the drink (pouring license) $1,500.00
$3,000.00
Retail liquor by the drink (pouring license)
$4,500.00
Pouring license (beer, wine, and liquor)
$1,200.00
Wholesale license
Farm Winery
$2,250.00
Catering License (offpremise)
$ 500.00
Application Fee (due 110011 returllillg applicatioll) $ 250.00
$ 50.00
Event Permit
$ 250.00
License Transfers
Temporary Permit (all fonus)
$ 250.00
u=V
~'O-rJJ~
1fCb
\\-
$
*Late Penalty *
fee
All renewal applications received after January 1 - 50% of license fee
Applicant's full name ---,---==-=...!....!""--':.....;",=--->-:'-"'-==-=--"---=-.-"''=!:::=---_ _ _ _ _ _ _ __
Name of business _--"-"'--'-..::.-='---'--=,..c...::.c::..:=---==-L...C:.-'-_ _-,-_ __ _ _ __ __
~~~~~~~~~~m~~~~~~~~~~:.
k~,-:::::...:~
com
CL'lpartnership, etc.)
MtP-ftNkf?&1J \J ! RAi:> I 'fA LLC-
Type of business organization (Corporation . !ted liab!!
Business mailing address & LH
Applicant's home address '374:1 I.
Applicant's age
4 CJ
M:,oI -£ S~~
Date of birth
'3-01
I
Phone 9 r2-~ 'i)') I ~ If'i II!t
~ fJ-t,iA) Phone j I'}..- l?') i ,..-Lfq I ~
Social Security # "
Are you a J%ident u.s. Citizen?
YES V
NO
--
--
\
Are yo~sident of Bulloch County?
YES - NO - -
1/ "No ", then you must designate a resident 0/ Bulloch County who shall be responsible/or
any matter relating to the license (ie., a "designee"). If you are appointing a designee, provide
the /ollowillg ill/ormatioll:
Designee's Name & Home Address _ _ _ _ _ __ _ _ _ __ _ _ _ _ _ _ _ __ _
Designee's Age _ _ _ _ _ _ __
Designee's Home Phone _ _ _ _ _ _ _ __
Designee's Date of Birth _ _ _ _ _ _ _ __ Designee' s SS# _ _ _ _ _ __
Are you the owner of the busineJS?
NO _V
'----_
YES
If"Yes", attach documentation demollstratillg your ownership o/tlle busilless, such as all
Operating Agreemellf, Partllership Agreement, or Shareholder's Agreemellt.
1/ "No ", wltat is your title or ifllerest in the busilless?
MA"1U ~r12List all partners, s~holders, members, or managers of the business below:
f!\--(Lc{~*rJ Mt;tV
V{ f7-.kD 1'1' (1(
A llaclt a copy o/your business 's Certificate o/Existence/rom tlte Secreta,)' a/State 's office.
BE ADVISED THAT ANY PARTNER, SHAREHOLDER, M EMBER OR MANAGER LISTED
ABOVE MUST COMPLETE A SEP ARA TE APPLICA nON AN 0 CONSENT FORM FOR A
BACKGROLIND CHECK AND IT IS YOUR RESPONSmILITY TO ENSURE THIS IS DON E.
Has the applicant or designee EVE..R been arrested for anything other than a traffic violation?
YES__
NO_~_
If "Yes", attach a detailed explanatioll to tltis applicatioll, alld be sure to provide the date,
jurisdictioll, offense, and circumstances o/tlle arrest.
Has the applicant or designee EVElkbeen denied an alcoholic beverage license?
YES
NO
J
If "Yes", attacll a detailed explanation to this applicatioll, alld be sure to provide tile date,
County or City, and circumstallces o/tlle dellial.
YES
NO~~
~__
If "Yes", attach a detailed explanation to this applicatioll, and be sure to pl'Ol'ide the date,
County 01' City, and circllmstances o/the sllspellsioll 01' revocation.
Approved _ __
Rejected _ __
This _ _
day of _ __ _ _ , 20_.
By: __~~__~~~~_____
J. Garrett Nevil, Chairman
Attest: _--:-.,-----:--=--=_ _:-:--=--:Maggie R. Fitzgerald, Clerk
\
CONSENT FORM
, hereby authorize the Bulloch County
Sheriff's Department to release information on any criminal history record the State of Georgia
or the Bulloch County Sheriff's Department might have access to concenring me to the Bulloch
I hereby agree that the Bulloch County Sheriff's Department, the Georgia Crime Information
Center, the employees of either agency, or any other agency or employees of the county, state or
federal government, shall not be responsible or liable for defamation, invasion of privacy,
negligence or any other claim in connection with any dissemination of information pursuant to
tlris record check.
FULLNAME: __~L
~~_'~
~
_· ~
~_-__~~~~
~
·J8~~~~~~
~
~__________________
Print or Type
ADDRESS:
8"'")4 \
\-\ lJ.> 'T >0\ ~ . ~ (l.,D~J / Cuf,,·. ?".-£J 'f- S qg
r
Street itddress
SEX:
Mk:1.X
RACE: UJ-'~'1 'f8'
City
State
DATE OF BIRTH:
Slgnatu
Date
'.
Zip Code
I,
LL{r(1rL~ ~C(~ ~hereby provide this statement under oath in
support of the application of UttfI'C--12... (2..oLe;rz.s :ac: (name of applicant) for an alcohol
license pursuant to the provisions ofthe Bulloch County Alcohol Ordinance.
I.
I am at least twenty-one (21) years of age, of good moral character, and a citizen of the
United Sates.
2.
3.
I have not been convicted of a felony or of any violations of the laws of the state of
years of the date of this application.
4.
I have not been denied or had revoked, within the five (5 ) years next preceding the date
of this application, any license to sell alcoholic beverages issued by any governmental
entity.
5.
I have read the Bulloch County Alcohol Ordinance in its entirety and am familiar with
serve alcohol for on-premises consumption. I wlderstand that the holding of an alcohol
6.
By execution of this affidavit and in consideration ofthe issuance of any license issued as
a result of this application, I agree to be bound by every provision of said Ordinance and
understand and agree that a violation of any provision of said Ordinance or of any law or
regulation of the state of Georgia pertaining to the sale of alcoholic heverages may
subject me to suspension or revocation ofthis license or criminal charges, or both.
7.
I swear and affinn that every entry upon my application is true and correct. I wlderstand
Occupation Tax Certificate, Alcohol License, Taxi Permit or other public benefit as referenced in
O.C.G.A. Section 50-36-1 , I am stating the following ~spect ~ application for a
Bulloch County Business Occupation Tax Cert~ficate, cohol Lice
Taxi Permit or other
public benefit (circle one) for LLtI1tvt. I.«)C<Efl..5
[Name of natural person applying on behalf of individual, business, corporation, partnership, or
other Priva7
gr.:
I)
I am a United States citizen
OR
2)
qualified alien or non-immigrant under the Federal Immigration and Nationality Act 18 years of
age or older and lawfully present in the United States. "
knowingly and willfully makes a false , fictitious, or fraudulent statement or
representation in an affidavit shall be guilty of a violation of Code Section 16-10-20 of
\\\ i ' \ '1 " ' 1111//
~""\\\Y';.~.~ !.~l 'l/I~'l
" 't--¥:.'S:,\ON E-t.o";1-9.', , ~~
~c, .'~'f.
~
:'o~
~ '. iC-;'
- ate
§ ;~ \'IO()~
-'
~~ ".
~
.~ ~
'20'" i·:() €
~~?: . . . .§
n
' . ,61&,
"C
-
Printed Name:
~~ ~.~~q~!! ~?':' ~<b?
"",prA
~ """
"/1" IiR'<
11 1\' \\\
SUBSCRlBED AND SWORN
BEFQRE ME ON. 11i~S THE
"24'bA Y OF t:.J Q..\v l# , 20 ~
~~.
Notary Public
Lt ~ 4
"
r 'l..D \1)...--
*Note: O.C.G.A. § 50-36-I(e)(2) requires that aliens under the federal Immigration and
Nationality Act, Title 8 U.S.C. , as amended, provide their alien registration number. Because
legal permanent residents are included in the federal definition of "alien", legal pennanent
alien registralionnwnber may supply another identifying number below:
'."
Friday, November 12, 2010
Response Key:
Page 1
.BUSX-
0460178 GA-CCH 20101112 08:27:35 20101112 08:27 : 35 201502DB8B
Georgia Crime Information Center
3121 Panthersville Road
Decatur , GA 30037
(404) 244 - 2639
***************** * ****
CRIMINAL HISTORY RECORD
Produced on
2010 - 11 -1 2
****************************
Introduction
***** * ** ***************
****************************
This rap sheet was produced in response to the following request:
FBI Number
State Id Number
ARN
267103RA1
GA1901995M (GA)
ALR A TO Z TRUCKS TOP
Purpose Code
Attention
NEVILS/KCM
E
The info rmation in this rap sheet is subject to the following caveats:
**THIS RESPONSE IS BEING PRODUCED FOR YOUR REQUEST SENT: 2010 - 11 -1 2
(GA; 2 007-08 -11 )
Important ! Crimina.l history record information is obtained one of t ....IO
ways : I} by conducting an inquiry using personal identifiers such as
name and date of birth (name search), or 2) by submitting fingerprint
cards to the Georgia Crime Information Center (GCIC). When conducting a
name search for crimi nal history record information, there is a
possibility that the information returned belongs to a different person
with the same , or similar , identifiers. In this case , a positive match
o f the person whose criminal history record is sought requires
submissi on of fingerprint cards to GCIC. When conducting a fingerprint
search for criminal history record information , the in formation
returned does , in fact, be long to the individual. In this case ,
conducting a name search us i ng the individual1s personal identifiers
would be the same information. (GA ; 2007-08 -11 )
When the information conta i ned in a criminal history report causes an
adverse employment or licensing decision the individual, business or
agency making the decision must inf o r m the applicant of all information
pert i nent to the decision. The disclosure must include information that
a criminal history record check was conducted, the specific contents of
the record and the effect the record had upon the decision. Failure to
provide all such information to t he person subject to the adverse
decision is a misdemeanor offense under Georgia law. Additionally, any
unautho rized dissemination of this record or information herein also
v i olates Georgia law. (Gl'. ; 2007 - 08-11)
In the event that identifiers are not clearly associated tp. ji~ l sp ~0fic ,,1
cycle , the information is most' likely non-fingerprint based/ ir,torm,{1: f<$i){ i :
received from the Department of Correct ions at the time of'-.; r'e I~asle l. ~fr!o'fu ,, 1
IDENTIFICATION
,.
,· ' 1
" \ t,j"
diO(';'.' .\,., i "11"1'
;If ; '~ I ~'I (;: I' ;i"1 ,) \ ~\!l1 'f)
, t-! I ' ! I r
!!.:} ,.•, ._ 1 \J •.. " IV J
. I
incarceration . (G.".; 2007 - 08 -11)
***** ************ *** ** *****
\
r '\
(il\ r I.f:.
*******
l
" • •• .
.: ~~~~
. ;.~* t**~2:'::~~__\) J~~ \(l.
I"
"'II,
II : . .·:i·
..
\ 'I' ;I"I0 r
' , I " " ( ' f ..... X I. ) , ..1 I.
.
1);J1e
I . , .'
Page 2
Subject Name(s)
ROGERS, LUTHER ROBERT
(2007 - 08 -0 8)
Subject Des c rip tio n
FBI Number
267103RAl
Sta te Id Number
G.lU901995M
Sex
Male (1996- 02 - 22)
White (1996 - 02-22)
Height
5 ' 06 " (1996- 02 - 22)
Weight
160 (1996 - 02 - 22)
Hair Co l or
Eye Color
Blue (1996 - 02 - 22)
Brown (1 996-02 - 22)
Race
Date of Birth
(2007 - 08-08)
Place of Birth
GEORGIA (1996- 02 - 22)
I I I Record
SSO
****** ** ******************
CRIMINAL HI STORY
****** ** *** * ********* ** ***
===================== OTN 00043 29 0085 (Cyc l e 1 of 2) ===============
Offender Tracki ng Number (OTN)
00 04 3290085
Earliest Event Date
1992 - 08 - 22
Offense Date
1992-08-22
Arrest SRF
43831756
Judicial SRF
45720073
Arrest
Arrest Date
Case Number
(C ycle 1 )
1992 - 08 - 30
Arresting Agency
Subject 's Name
Arrest Type
GA0160000 BULLOCH COUNTY SHERI FFS OFFICE
ROG ERS , LUTHER:ROBERT
Adult
Charge
Charge Trac king Number
Charge Lit eral
Statute
State Offense Code
Severity
00 0 4 3290085 - 1
TERRORISTIC THREATS AN D ACTS
1 6-11-37; GA
1386
Felony
Court Dispositi on
Case Number
Court Agency
Sub ject's Name
GA0 160i5J
Charge
Charge Literal
00043290085 - 1
TERRORISTIC THREATS AND ACTS
(Cycle - l)
\,
Statute
State Offen se Code
Seve rity
Disposit i o n
Page 3
16-11 - 37 ; GA
1386
Felony
NO BILL (1993 - 02 - 01; Acquit te d)
~~ ~~~~~~~ ~~~ ~~ ~ ~ ~~ ~~~ OTN 00038803015
(Cycle 2 of 2) ~~~~~ ~ ~~~~~~ ~~~
Offender Tracking Number (OTN)
00038803015
Earliest Even t Date
1996- 02- 22
Offe nse Date
1996- 02 - 22
Arrest SRF
56762133
J udicia l SRF
60221815
Arrest
Arrest Da te
Case Number
Arresting Agency
Subject ' s Name
Arrest Type
Charge
Charge Tra cking Number
Charge Liter al
Stat ute
State Offense Code
Severity
(Cyc le 2)
1996- 02 - 22
9600 2241
GA1020100 FORSYTH POLICE DEPARTMENT
Adul t
00038803015 - 1
DRIVING WHILE LI CENSE SUSPENDED OR REVOKED (MISDEMEANOR)
40 - 5 - 1 21 (1'.) ; GA
5412
Misdemeanor
Cour t Di sposition
Case Number
Cou r t J.\. gency
Subject ' s Name
(Cycl e 2 )
1 2338
GA102013J
ROG ERS, LUTHER ROBERT
Charge
Charg e Tracking Number
Charge Literal
Stat ute
S ta te Offense Code
Severity
000388030 15 -1
DRIV ING WHILE LICENSE SUSPENDED OR REVOKED
40 - 5 - 12 1 (A) ; GA
54 1 2
Dispo sition
Sentencin g
Case Number
Senten ce Date
Sentencing Age n cy
Charge
Cha rge Tracking Number
Se nte nce
Misdemeanor
GUILTY (CONV I CTED / ADJUDICATE D)
Convicted)
(1996 - 03 - 28 ;
(Cycle 2)
1996- 03-28
GA10 2 013J MONROE COU NT Y PROBATE COURT
00038803015 - 1
FINE $132
PROBATION
12 MONTHS :
******************* ******
Age n cy
(M I SD E t~ E ANOR)
INDEX OF AGENCIES
**************************
BULLOCH COUNTY SHERIFFS OFFI CE; GA0160000;
SHERI FF
Address
1725 7 HIGHWAY 301 NORTH
STATESBORO , GA 30458842 1
Agency
Page 4
BULLOCH COUNTY SUPERIOR COURT ; GA016015J;
JUDGE
Address
20 SIEBALD STREET
Agency
FORSYTH POLICE DEPARTMENT; GA1020100;
CHIEF
Address
PO BOX 14 47
FORSYTH , GA 3 10 290000
Agency
MONROE COUNTY PROBATE COURT ; GAI02013J;
JUDGE
Address
PO BOX 187
FORSYTH , GA 310290000
* * * END OF RECORD * * * U·
'.
Public Safety: Sheriff, Administration: County Clerk
To grant alcoholic beverage renewal licenses for package retail beer and wine, retail beer and wine by the drink,
pouring, and farm winery sales to establishments with a 2010 license.
Please see the attached list for recommendations for approvals and denials.
BUDGETED ITEM?
PRESENTATION
PUBLIC HEARING
CONSENT
NEW BUSINESS
OLD BUSINESS
OTHER
x
1---;-;,~+---1 REQUIRED?

2010-201 - Bulloch County

Transcription

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